Abstract: Introduction: The practice of orthodontics is very young in South-South Nigeria and there is need for base line data for informed planning. This study was carried out to investigate the self-perception of malocclusion among Nigerian school children aged 12 to 18 years in order to compare their perception with that of an orthodontist and also to determine the influence of gender and age on self-perception. Materials and Methodology: A total of 612 randomly selected schoolchildren comprising 299 (48.9%) males and 313 (51.1%) females with a mean age of 15 + 2.0 years were included in the study, the Aesthetic Component (AC) of the Index of Orthodontic Treatment Need (IOTN) was the instrument used to measure the perception of malocclusion by both the school children and the orthodontist. Results: Majority of the students (82.5%) rated their teeth towards the more attractive end of the scale (Grades 1-4). Although self - perception was not found to be related to gender, older children (16-18 years) had an increased level of perception of need. Males and older children were found to be more in need of treatment by the orthodontist. Conclusions: A significant difference was found between the orthodontist’s rating and the students’ ratings of the attractiveness of their occlusions. Age and gender were not found to influence self- perceived orthodontic treatment need. Therefore, for effective orthodontic care, self- perception and not only professional assessment must be taken into consid- eration when formulating treatment plans to ensure patient satisfaction.

INTRODUCTION The Aesthetic Component (AC) of the Index of Ortho-

dontic Treatment Need (IOTN) (Fig. 1), which is a scale ofHuman self-esteem and self-confidence depend to a large ten photographs of the occlusion of anterior teeth is a stan-degree on an acceptable physical appearance, well propor- dardized method of assessing dental aesthetics [2,13]. Datationed facial features, properly aligned teeth and a pleasing concerning self-perception of malocclusion based on thisattractive smile [1]. However, the cosmetic impairment of a index, are available for many populations with figures rang-particular malocclusion is not readily measured because per- ing from 8% to 38% [3, 6,14-24]. However, no such data areceptions of malocclusions are highly subjective and per- available for Nigerian adolescents residing in Rivers State; aceived by individuals more qualitatively than quantitatively place where the practice of orthodontics is relatively new.[2]. Most occlusal indices define aesthetics and ultimatelyorthodontic treatment need from a clinicians point of view Therefore, this study aimed at investigating the self-only (normative need) without considering patients’ social perception of malocclusion among Nigerian school childrenneeds. But, perception of dental aesthetics by patients cannot aged 12 to 18 years using the Aesthetic Component ofbe under estimated because they are the ones receiving IOTN, and to compare their perception with that of an ortho-treatment and need to gain satisfaction from improved aes- dontist as well as to determine the influence of gender andthetics [3, 4]. In most people, the demand for orthodontic age on self-perception.treatment is related to their desire to improve their appear- MATERIALS AND METHODOLOGYance and their degree of attractiveness [3, 5-12]. A total of 612 students aged 12 to 18 years were ran- domly selected from six (6) public schools in six (6) differ-*Address correspondence to this author at the Department of Child Dental ent Local Government Areas (Port Harcourt, Ikwerre,Health Dental Centre University of Port Harcourt Teaching Hospital Port Omuma, Tai, Okrika and Asari – Toru) located across RiversHarcourt, Nigeria; Tel: +2348033131969; State, Nigeria. Ethical approval was sought and obtainedE-mail: elfledaaikins@yahoo.com from the Ethics Committee of the University of Port Har-

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62 The Open Dentistry Journal, 2012, Volume 6 Aikins et al.

The examination was carried out by one author (EAA)

who had been previously calibrated in the use of the AC of the IOTN by a senior colleague (COO). None of the students had undergone any form of orthodontic treatment. The students also assessed their own occlusions using the same scale (AC of the IOTN) and rated their occlusions according to the photograph which most closely matched the attractiveness of their own teeth. INTRA EXAMINER RELIABILITY Intra-examiner reliability was tested using Spearman Rank Correlation Coefficient. Sixty-two students were re- examined a month after their initial examination. A result of 0.94 was obtained, indicating excellent agreement. STATISTICAL ANALYSES The data was analyzed statistically using the SPSS statis- tical package (Statistical Package for the Social Sciences Version 17.0 for Windows 2009, SPSS, Inc., Chicago, Illi-Fig (1). The AC of the IOTN (Brook and Shaw, 1989) nois). Descriptive statistics were used to describe the sub-1-4 indicates no need. jects’ perception of their dental aesthetics as compared to the5-7 indicates moderate need. normative assessment. T-test and chi-square statistics were8-10 indicates definite need used to analyse the data with statistical significance set at P<0.05. A matrix of Spearman Rank Order Correlation Coef-court Teaching Hospital. Informed verbal consent was ob- ficients was constructed for comparison of self-perceivedtained from each of the participants. The data was collected dental aesthetics of the subjects with normative assessment.in the school compound during school hours under standard- Logistic regression analysis was used to determine the influ-ised lighting conditions, with the student seated and the teeth ence of sex, age and self assessment of need by participantsin centric occlusion. on professional assessment of need. Preliminary analyses A full intraoral examination was carried out using a were performed by using univariable models. Next, a multi-wooden spatula and each student’s anterior teeth were as- ple logistic regression analysis was then performed to re-sessed using the AC of the IOTN with grade 1 as the most move the effects of age, sex and self-assessment of needattractive and grade 10 as the least attractive (Fig. 1). The which serve as the confounding factors to produce the ad-grades of the AC which correspond to the numbers on the justed odd’s ratios.respective photographs, depicting the levels of treatmentneed are as follows: RESULTS AC Grades 1- 4: No need for orthodontic treatment. Table 1 shows the gender and age distribution of the AC Grade 5-7: Borderline / Moderate need for orthodon- sample comprising 299 (48.9%) males and 313 (51.1%)tic treatment. females with a mean age of 15 + 2.0 years. The mean age for the males was 14.9 + 1.9 years, whilst that for females was AC Grade 8-10: Definite need for orthodontic treatment. 15.0 + 2.0.

Student’s t test (independent) = 0.82, p = 0.42

Table 2. Gender Distribution of Self-Assessment and Professional (Orthodontist) Assessment of Dental Aesthetics of the Studied Population According to the Aesthetic Component of the Index of Orthodontic Treatment Need

ORTHODONTIST PERCEPTION OF DENTAL older children (16 -18 years) rating their teeth in need ofAESTHETICS orthodontic treatment as compared with the younger school- children, the difference was not statistically significant (p Orthodontist rating revealed that 64.9% (397 students) >0.05). There were almost equal numbers of male 55(18.4%)had no need for treatment (grades 1–4), 17.5% (107 stu- and female 52(16.7%) students rating themselves to be indents) had a moderate need (grades 5–7) and 17.6% (108 need of orthodontic treatment. Hence, self perception is notstudents) had a definite aesthetic need (grades 8–10) for or- statistically different between genders.thodontic treatment (Table 2). ASSOCIATIONS BETWEEN ORTHODONTIST PER-ORTHODONTIST PERCEPTION COMPARED BY CEPTION AND SELF-PERCEPTIONAGE AND GENDER Using Pearson Correlation Coefficient, a weak but There were significant statistical differences between significant correlation was found between the orthodontistage, gender and the normative orthodontic need as assessedby the AC. Thirteen year-olds had the least orthodontic rating and the students’ self-perception (r = 0.24, P= 0.00).treatment need of 25% whilst 17 year-olds had the greatest One hundred and eight students were rated by the orthodon-need for treatment of 43.5%. Male students were statistically tist to have a definite aesthetic need for orthodontic treat-(p=0.00) found to have a greater need for treatment (41.5%) ment, out of which 22 also rated themselves likewise. Whilstthan female students (29.1%) (Table 3). A multivariate 107 of the students were rated by the orthodontist as havinganalysis revealed that as age increased by one unit, partici- a moderate need, only 16 were in agreement with this rating.pants were 1.1 times more likely to have a professional need Meanwhile, out of the 397 students assessed not to have afor treatment. Males were 1.76 times more likely to have need, 351 of them rated themselves similarly (Table 6). Theprofessional need than females (Table 4). students who perceived themselves to have a need for treat- ment were 2.91 times more likely to have a professionalSELF PERCEPTION OF DENTAL AESTHETICS need than those without a self-perceived need (Table 4). However, when the students were asked to rate their own DISCUSSIONdental attractiveness, 505 (82.5%) scored their teeth as aes-thetically acceptable (grades 1–4), 67 (10.9%) as moderate The perception that potential patients have of the need for(grades 5–7) and 40 (6.5%) rated their teeth from grades 8 to orthodontic treatment cannot be ignored because it is these10 (Table 2). patients that gain satisfaction from improved aesthetics andSELF PERCEPTION COMPARED BY AGE AND even function [3, 4, 10]. Thus, the knowledge of self- per-GENDER ception of malocclusion, assessment of orthodontic treatment need, (self-perceived as well as professional) and their com- As depicted in Table 5, majority of the students in each parisons for any given population are vital issues in modernage group rated their teeth towards the more attractive end of orthodontic practice.the scale. Though there was an increase in the proportion of64 The Open Dentistry Journal, 2012, Volume 6 Aikins et al.

Table 3. Relationship Between Age, Gender and Professional (Orthodontist) Assessment of Need According to the Aesthetic Compo- nent of the Index of Orthodontic Treatment Need

In Rivers State, Nigeria, where this study was carried out, Jordan [19], females and older school children tended to ratethe practice and teaching of orthodontics is relatively new. their dentition towards the more attractive end of the ACThus, this cross-sectional study of self- perception of maloc- scale whereas in a Latvian study [33], female children feltclusion in 612 randomly selected 12 – 18 year-old Nigerian more in need of treatment than male children.secondary schoolchildren residing in Rivers State will pro- There were significant gender and age differences in thevide valuable data for the adolescents residing in the State orthodontist’s assessment of treatment need, (p< 0.05). Theand allow for informed planning of orthodontic services. increase of orthodontic treatment need with age seen in this Research has proven that most patients seek orthodontic study is probably due to the fact that untreated malocclusiontreatment principally for aesthetic improvement [5, 25]. worsens with age as the permanent occlusion becomes estab-Teenagers, in particular have been found to attach great im- lished [34]. When assessed professionally, male adolescentsportance to an attractive dental appearance [3, 7, 8, 10, 16, had a significantly greater need for treatment than females.26] and have also been shown to have developed an oral per- This is consistent with the findings of Burden et al. [35], butceptual awareness [27, 28]. Adolescence is the time when at variance with the findings by Onyeaso [36] where moreconcern over appearance and facial attractiveness is develop- females were found to be in need of treatment than males.ing, which translates to an increased awareness of body im- However, it must be noted that the finding by Onyeaso [36]age [6]. Thus, the self perception of malocclusion is an im- was in a demand population and more females sought ortho-portant parameter in treatment planning for adolescent popu- dontic care in that Nigerian study. It also disagrees with thelations. findings from other studies conducted in Nigeria [8, 10, 32, 37], Tanzania [6], Senegal [29], France [38], Kuwait [18], In this study, using the AC, 17.5% of the students per- Latvia [33] and Iran [39] where there were no gender or ageceived a need for orthodontic treatment. This result is higher differences. Although, our findings corroborate that of Bur-than that of a similar study carried out in South- WesternNigeria by Kolawole et al. [22] with treatment need of 8% in den et al. [35], no adequate explanation can be made for this gender difference.11 – 14 year-olds and that obtained by Ngom et al. [29] in 12to 13 year-olds in Senegal (13.9%). These differences may In this study, a weak but positive correlation between selfbe as a result of ethnic variation and the wider age range of - perceived and normative orthodontic treatment need ac-the adolescents in this present study. Ethnicity does have an cording to the AC of the IOTN was obtained. This is compa-effect on self-perceived need due to differences in acceptable rable to that obtained in a study carried out on schoolchildrenfacial appearances and what is deemed as acceptable occlu- by Kolawole et al. [22] in Western Nigeria (r = 0.252,sion by different ethnic groups, it would be useful to validate p=0.00) and Kerosuo et al. [18] (r = 0.209, p= 0.05) in Ku-the IOTN in different ethnic groups. This figure (17.5%) is wait but lower than the figure obtained by Otuyemi et al.also higher than the subjective need found in the U.K. (6%) [32] (r = 0.35) in a previous study also carried out much ear-[30], Jordan (9%) [19], Saudi Arabia (14.5%) [1], and Peru lier in South-Western Nigeria.(12.8%) [31]. It is, however, comparable with 18.7% foundin Saudi Arabia among 11-16 year-olds [20] and 5.8% defi- CONCLUSIONSnite need obtained in Malaysia [24] but much lower than A significant difference was found between the orthodon-65% and 21.8% subjective need, respectively reportedamong visually and hearing impaired Saudi Arabian adoles- tist’s rating and the students’ ratings of the attractiveness ofcents [20]. their occlusions. Age and gender were not found to influence self- perceived orthodontic treatment need. Therefore, for In the present study, there were no significant age or effective orthodontic care, self- perception and not only pro-gender differences in the participants’ self-perceived need fessional assessment must be taken into consideration whenfor orthodontic treatment, and this is probably due to the formulating treatment plans to ensure patient satisfaction.subjects’ general lack of awareness of the presence of mal-occlusion. This finding is in agreement with a previous Nige- ACKNOWLEDGEMENTrian study [8],where almost equal numbers of male (79.8%)and female (83.6%) participants respectively perceived a None declaredneed for treatment (p>0.05) as well as other studies in U.K. CONFLICTS OF INTEREST[23, 30] Saudi Arabia [1] and U.S.A. [28] However, in otherstudies carried out in South-Western Nigeria [32] and North None declared. 66 The Open Dentistry Journal, 2012, Volume 6 Aikins et al.

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